With 15 trips already on the books in 2018, Laura Williard anticipates another busy year. For Williard, AAHomecare’s payer relations specialist, the last few months of 2017 were busy. About a year and half has passed since she took on a newly-created position in the HME-centric organization. Since taking on that role, Williard travels extensively to talk in person with providers and state associations.
The mission: explaining the changing Medicare and Medicaid landscape, and what AAHomecare is doing in regards to that. With the 21st Century Cures Act Medicaid-related provisions in effect and with Medicare cuts already in place, managed care plans and home health equipment providers face another tough year, Williard says.
What is your role?
“I provide support and serve as an advocate for medical equipment providers. I like the advocacy role—fighting for providers and patients. I have never stopped believing that we will not only survive, but will actually thrive. I have seen the heart and passion of providers in being able to service patients. With that much heart and soul in our industry, it’s hard not to be optimistic that things will improve.”
“Some of what I do is build relationships with state Medicaid directors, particularly as Medicaid Cures comes out. But my main relationship is with the state associations and key providers. I’m there for support, to help guide them. If one state is doing something that is effective, you want to pass that information along to other states. I’m helping pull those groups together. And I like to do things in person. It shows a level of respect.”
What are the key projects?
“We work very closely with state associations and state leaders. We try to influence CMS [Centers for Medicare & Medicaid Services] as the Cures provisions are rolled out.” “We’re looking to open networks. That will help provide a quality of care and quality of products. In this environment—especially the Medicaid program—people just don’t know what’s going to happen.”
“We put together resources to try to keep those networks open so there will be more competition, which should provide more access to multiple providers.”
What are the biggest concerns?
Pricing has created an environment where a company has to run its business at a loss, according to Williard. There will be some companies that say, “I can’t provide services anymore.”
The change in Medicaid means reimbursement to state programs from the federal match cannot exceed the competitive bidding rates, Williard says.
Because Medicare sets the market rate, when those “drastic” 50 percent reductions occurred, managed care plans also took a discount off the already reduced rates.
“In the managed care world, they are being pressured with others coming in offering lower premiums…thinking ‘Medicare’s reduced their rates, we should take a look at that.’ What we’re seeing is that by Medicare Advantage drastically reducing rates, it narrows networks in a lot of states.”
If a company can’t provide equipment or services for what Medicare will pay, patients have to shop around. That interrupts the continuity of the patient’s care. In addition, as equipment providers cut back on products they can afford to deliver, patients have to dig deep and pay out-of-pocket for some products, according to Williard. It affects the bottom line for equipment providers.
What tips do you share with providers?
“For a new provider that is finally in the network, they’re excited, so they don’t analyze it to determine true costs.”
“They need to think in terms of a contract negotiation when entering a new agreement with a payer. They should have someone fully focused on that. It’s about a quality-based performance fee schedule. They need to understand everything in the contract. The appeals process is one of those things providers don’t always pay attention to. What happens if there is a dispute?”
“As far as the fee schedule, providers really need to look at the overall costs of doing business. What guidelines are required for the authorization process? They need to consider specifics of clinical requirements. How much time is required? Are filing deadlines negotiable?”
“Also, be aware that if you are negotiating outside a standard contract, you have to stay on top of it. Make sure the payer is following those specifics of your contract, as opposed to a standard legal contract. There are opportunities to negotiate all the things.”
“It’s really about building relationships and re-visiting it.”
So, what’s the fix?
HR 4229 is the No. 1 legislative priority right now, according to Williard. HR 4229 provides relief for providers suffering from the expansion of competitive bidding to rural and non-bid areas. The bill would return Medicare pay to pre-2016 rates, affecting not just Medicare recipients, but those on Tricare, CHIPS and Medicaid.
“It impacts every patient who has one of these plans. The main goal is to show there is still that support and to push that through now. When they passed Medicaid Cures, they didn’t think of the trickle-down effect of a flawed competitive bidding program. Legislators know that now.”
“It’s all about making the pay rate sustainable while providing excellent service to patients.”
AAHomecare supports audits, but the entire program is over-cumbersome and the appeals process does not work, according to Williard.
“We want good quality providers in the business. Although audits are good for keeping fraudulent providers out of the business, the current audit process is dysfunctional, and the appeals process is broken.”
It takes an average of 1,042 days to get an item through the appeals process. The denial rate has continued to increase, with 37 percent of all hospital beds, wheelchairs and support services audited in pre-pay audits. That increases cost for providers.
“About 71 percent of pre-pay audits are paid on review, so why waste the time and energy to do this at that drastic of a level?”
Another goal for advocates is to work through what is so costly in the medical supplies industry. It’s over regulated, and it is out-of-control, according to Williard.
“The new administration has proven to be a more provider-friendly one and has been open to making changes from a regulatory standpoint. We see a positive trend coming from that aspect.”
Read the full February cover series here.